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Based on follow up visit, review of the Quality Assessment and Performance Improvement (QAPI) Program, and interview with the Quality Coordinator (employee #5), it was determined that the facility governing body, medical staff, and administrative officials failed to be responsible and accountable to the Quality Assessment Program.

Findings include: Deficiencies Not corrected

During Interview with the Quality Coordinator (employee#5) on 9/6/16 at 2:00 pm during the follow up visit she stated that " The Quality program Committee was established, the first meeting was performed on August 19, 2016, in this meeting was presented the committee members, the committee structure was presented quality, standardized formats improving the quality and performance were approved. I discussed the timely review of reports on time surveillances. The next meeting was on 9/22/16 but the administrator was absent. Of the department were not up to date the report of the indicators, all are current except Medical Faculty Emergency Room that did not reports the indicator inform since March 2015. The Medical Director from Emergency room changed. On 8/23/16 I performed a meeting with them I provide an orientation related to all indicators from the emergency room. I gave to him the template of quality indicators which are: Transfers, Leaks, exonerations, Deaths, Rebounds before 24-48 hours Evaluation of Peer Reviews. The administrator was notified related to this situation and related to the facultative Director of emergency room orientation. At this moment no quality indicator report from the Medical Facultative Emergency room. The other department that was late for 2-3 month sending the quality indicator report was pathology that it a contracted service, the administrative was notified " .

1. During the review of the Quality Assessment Program, Activities, Manual it was determined that the facility governing body failed to be responsible to support and maintain effective communication and maintain quality program integrated. Due to all services did not report their indicator according to Quality Assessment Program schedule.

Based on interviews with the Acting Nurse Director (employee #1) and Human resources officer (Employee #2) on 09/06/16, it was determined that the facility failed to have a Director of Nursing assigned to ensure a organize nursing services with a plan of administrative authority and delineation of responsibilities for patient care, developing a legible nursing job schedule according to the professional standards of practice and according the hospital rules and regulations.
Findings include: Deficiency not corrected
On 09/06/16 at 10:30am during interviews with the employee #1 state " Yes I am the Acting nursing director. The facility is working with the Bachelor Degree Nurse (BSN) position for the different units " .
On 09/06/16 at 11:25 am during interviews with the employee #2 state we continued evaluating candidates for the position of Nursing Director. About the BSN positions we are evaluating the facility Associates degree nurse (ADN) who is studying for BSN for those positions.
According with the Law Number 254 of December 31 of year 2015 '' To Create the new law to regulate and adjust the nursing practice to the actual world at the " Estado Libre Asociado de Puerto Rico; establish the new Board of Nursing Examination " Junta Examinadora de Enfermería " ; regulate everything related to the license or certification; to establish penalties; provide the operational funds of the Professional Board; and derogate the Law Núm. 9 of October 11, 1987, as amended.'' Eposes on page 13 ( f ) Associate Degree Nurse (ADN) can provide services under contract with agencies or persons only if she function under the direction and supervision of the generalist nurse (BSN) or advance practice nurse MSN.

Based on follow up survey and medical record review with the discharge planer employee #6, it was determined that the facility failed to ensure that the nursing staff develops, and keeps current, nursing care plans for each patient for 3 out of 8 record review. (RR #2, #3 and #4)

Findings include: Deficiencies Not corrected

1. R.R #2 is a 65 years old male admitted on 8/30/16 with a diagnosis of Sepsis and infected sacral ulcer. Accordance to the review of medical record performed on 9/6/16 at 9:25 am with the discharge planer employee #6 it was found the following:
a. On 8/30/16 at 11:30 am the physician activate the insulin scale protocol with destrostix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personnel. However, during the stay in medicine ward from 8/30/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system. The registered nurse (RN) only wrote the date 8/30/16, but did not individualized the standardized plan of care for the endocrine system. Patient was admitted with infected sacral ulcer, the RN but the date in the Plan of care 8/30/16, but did not individualized the standardized plan of care for the intergumentary system.
b. On 8/30/16, the RN documented in the nurses note (flow sheet) in the intergumentary system see skin care sheet. However, no evidence was found related to ulcer characteristic and the care provided to the sacral ulcer stage III and elbow ulcer stage IV.
c. Patient has a foley catheter #16 that comes with it from home. On 8/30/16 3-11 shift the RN documented that the foley catheter was changed with urine culture before and after change. However failed to document the size of the foley catheter. On 11-7 shift in the flow sheet the RN mark yes to the foley and write #16, but in the narrative nurse ' s note documented that the foley catheter was size #18. On 9/1/16, the RN did not document the foley size. On 9/2/16 The RN documented foley catheter #16. The RN failed to documented congruent nurse note related to the real size of the foley catheter without discrepancy
2. R.R #3 is a 97 years old male admitted on 8/27/16 with a diagnosis of Multiple Skin Ulcer Infected. Accordance to the review of medical record performed on 9/6/16 at 11:00 am with the discharge planer employee #6, it was found the following:
a. On 8/31/16 at 8:30 am the physician ordered discontinue the foley catheter. On nurses note documented on 8/31/16 the RN documented that he urine was with hematuria previous to discontinue the foley catheter. Then of 7-3, 3-11 and 11-7 shift of 8/31/16 the nurse documented that patient was with hematuria in the disposable diapper. On 9/1/16 and 9/2/16, no evidence was found in the nurse ' s note related to if patient was urine spontaneous and characteristic of the urine previous to the discharge on 9/2/16.
3. R.R #4 is an 84 years old male admitted on 8/30/16 with a diagnosis of Acute Ischemic Heart Disease. Accordance to the review of medical record performed on 9/6/16 at 11:30 am with the discharge planer employee #6, it was found the following:

a. On 9/1/16 at 11:30 am the physician activate the insulin scale protocol with destrostix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personnel. However, during the stay in medicine ward from 9/1/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system. On 8/30/16, the RN activate the plan of care of intergumentary system, however did not identified the problem in the intergumentary system.
b. On 9/2/16 the physician ordered discontinue the foley catheter, that be done by the nurse on 7-3 shift, however no evidence was found in the nurses documentation if patient continue urine spontaneous.

Based on follow up survey and medical record review with the discharge planer employee #6 , it was determined that the facility failed to ensure that al medical record are legible, complete, dated, timed, and authenticated in written by the person responsible for providing or evaluating the service provided for 3 out of 8 record review (R.R.#2, #3 and #4)

Findings include: Deficiencies Not Corrected

1. R.R #2 is a 65 years old male admitted on 8/30/16 with a diagnosis of Sepsis and infected sacral ulcer. Accordance to the review of medical record performed on 9/6/16 at 9:25 am with the discharge planer employee #6 it was found the following:
a. On 8/30/16 at 11:30 am, the physician activate the insulin scale protocol with destrotix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personal. However, during the stay in medicine ward from 8/30/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system. The registered nurse (RN) only writes the date 8/30/16, but did not individualized the standardized plan of care for the endocrine system.
b. Patient was admitted with infected sacral ulcer, the RN write the date in the Plan of care 8/30/16, but did not individualized the standardized plan of care for the integumentary system.
c.. On 8/30/16, the RN documented in the nurses note (flow sheet) in the integumentary system see skin care sheet. However, no evidence was found related to ulcer characteristic and the care provided to the sacral ulcer stage III and elbow ulcer stage IV.
d. Patient has a foley catheter #16 that comes with it from home. On 8/30/16, 3-11 shift the RN documented that the foley catheter was changed with urine culture before and after change. However, the RN failed to document the foley catheter size. On 8/30/16 at 11-7 shift in the flow sheet the RN mark yes to the foley and write #16, but in the narrative nurses note documented that the foley catheter was size #18. On 9/1/16, the RN did not document the foley size. On 9/2/16 the RN documented foley catheter #16. The RN failed to documented congruent nurse note related to the real size of the foley catheter without discrepancy.
2. R.R #3 is a 97 years old male admitted on 8/27/16 with a diagnosis of Multiple Skin Ulcer Infected. Accordance to the review of medical record performed on 9/6/16 at 11:00 am with the discharge planer employee #6, it was found the following:
a. On 8/31/16 at 8:30 am the physicians ordered discontinue the foley catheter. On nurses note documented on 8/31/16 the RN documented that the urine was with hematuria previous to discontinue the foley catheter. Then of 7-3, 3-11 and 11-7 shift of 8/31/16 the nurse documented that patient was with hematuria in the disposable diaper. On 9/1/16 and 9/2/16, no evidence was found in the nurse ' s note related to if patient urine spontaneous and characteristic of the urine previous to the discharge on 9/2/16.
3. R.R #4 is an 84 years old male admitted on 8/30/16 with a diagnosis of Acute Ischemic Heart Disease. Accordance to the review of medical record performed on 9/6/16 at 11:30 am with the discharge planer employee #6, it was found the following:

a. On 9/1/16 at 11:30 am the physician activate the insulin scale protocol with destrotix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personal. However, during the stay in medicine ward from 9/1/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system.
b. On 8/30/16, the RN activate the plan of care of integumentary system, however did not identified the problem in the integumentary system.
c. On 9/2/16 the physician ordered discontinue the foley catheter, that be done by the nurse on 7-3 shift, however no evidence was found in the nurses documentation if patient continue urine spontaneous.

Based on follow up survey and medical record review with the discharge planer employee #6, it was determined that the facility failed to ensure that clinical records have complete documentation related to nurse's notes, 3 out of 8 record review (R.R.#2, #3 and #4)

Findings include: Deficiencies Not Corrected

1. R.R #2 is a 65 years old male admitted on 8/30/16 with a diagnosis of Sepsis and infected sacral ulcer. Accordance to the review of medical record performed on 9/6/16 at 9:25 am with the discharge planer employee #6 it was found the following:
a. On 8/30/16 at 11:30 am, the physician activate the insulin scale protocol with destrotix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personal. However, during the stay in medicine ward from 8/30/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system. The registered nurse (RN) only writes the date 8/30/16, but did not individualized the standardized plan of care for the endocrine system.
b. Patient was admitted with infected sacral ulcer, the RN writes the date in the Plan of care 8/30/16, but did not individualize the standardized plan of care for the integumentary system.
c.. On 8/30/16, the RN documented in the nurses note (flow sheet) in the integumentary system see skin care sheet. However, no evidence was found related to ulcer characteristic and the care provided to the sacral ulcer stage III and elbow ulcer stage IV.
d. Patient has a foley catheter #16 that comes with it from home. On 8/30/16, 3-11 shift the RN documented that the foley catheter was changed with urine culture before and after change. However, the RN failed to document the foley catheter size. On 8/30/16 at 11-7 shift in the flow sheet the RN mark yes to the foley and write #16, but in the narrative nurses note documented that the foley catheter was size #18. On 9/1/16, the RN did not document the foley size. On 9/2/16 the RN documented foley catheter #16. The RN failed to documented congruent nurse note related to the real size of the foley catheter without discrepancy.
2. R.R #3 is a 97 years old male admitted on 8/27/16 with a diagnosis of Multiple Skin Ulcer Infected. Accordance to the review of medical record performed on 9/6/16 at 11:00 am with the discharge planer employee #6, it was found the following:
a. On 8/31/16 at 8:30 am the physicians ordered discontinue the foley catheter. On nurses note documented on 8/31/16 the RN documented that the urine was with hematuria previous to discontinue the foley catheter. Then of 7-3, 3-11 and 11-7 shift of 8/31/16 the nurse documented that patient was with hematuria in the disposable diaper. On 9/1/16 and 9/2/16, no evidence was found in the nurse ' s note related to if patient was urine spontaneous and characteristic of the urine previous to the discharge on 9/2/16.
3. R.R #4 is an 84 years old male admitted on 8/30/16 with a diagnosis of Acute Ischemic Heart Disease. Accordance to the review of medical record performed on 9/6/16 at 11:30 am with the discharge planer employee #6, it was found the following:

a. On 9/1/16 at 11:30 am the physician activate the insulin scale protocol with destrotix (glucose level test) every 6 hour (4:00 am- 10:00 am-4:00 pm-10:00 pm), that was performed by the nursing personal. However, during the stay in medicine ward from 9/1/16 thru 9/6/16, no evidence was found that nursing staff develops and keeps current the nursing care plan to the problem with the endocrine system.
b. On 8/30/16, the RN activate the plan of care of integumentary system, however did not identified the problem in the integumentary system.
c. On 9/2/16 the physician ordered discontinue the foley catheter, that be done by the nurse on 7-3 shift, however no evidence was found in the nurses documentation if patient continue urine spontaneous.

Based on observations, controlled substance count, emergency carts check, medications carts verifications, medications storage check and interviews, it was determined that the facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Findings include: Deficiency not corrected

1. On 09/06/16 at 9:15 am a tour was perform with the Pharmacy Director (Employee #3) for the verification of proper storage of the drugs and biological

a. On 09/06/16 at 9:23 am on the 3rd floor medical surgical ward accompany with employee #3 it was found one of the medication cart unsecured and with no custody in the hallway, employee # 3 state that the facility install a new lock to the two medications carts that she did not know why is open.
The facility failed to ensure that all drugs and biological are stored in a proper and safe manner accessible only to authorized personnel.

Based on observations performed on a follow up visit made during the survey on 09/06/2016 for the physical environment , it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well-being of patients receiving services.

Findings include: Deficiency not corrected

1. Intensive care Unit
a. All the nursing station chairs are covered with cloth and it were observed dirty.
b. The surgical medical storage are untreated wooden material and the storage have a strong odor of humidity.
c. The isolation room: The door frame was observed unattach from the wall and deteriorated.
2. Kitchen:
a. The fridge floor entrance was observed with rust.
3. The security Camera room:
a. All ceiling tiles out of place. A lot of cables crossing the ceiling without straps.
4. Morgue (Cold room)
a. It was observed that the walls are covered with a material (Insulation) that not permitted a proper sanitization and disinfection of the room.
b. It was observed the room without clean.
c. It was observed a lot of condensation inside the room.
d. No temperature, humidity and cleaning log report was provided.
5. The hospital's laundry was visited and provided evidence that the flow of dirty linen to the washer machine, to the dryer and then to the clean linen folding table does not move in one direction (from dirty to clean). The dirty linen cart enters past the clean linen folding table and stops in front of the washer, after the linen are washed they go towards the back of the room to the dryer and when they finish drying they pass by the dirty linen cart and washer to get to the clean linen folding table near the main entrance. This procedure increases the risk of cross contamination of the clean linen with the dirty linen.

Based on observations made during the follow up visit performed on 9/6/2016 survey for the physical environment ,it was determined that this facility's physical structure is not designed in accordance with Federal and State laws to provide protection of patients and staff.

Findings include: Deficiency not corrected

3. The operating room department was visited and provided evidence of the following:
a. The pre-induction lounge chair area (seven lounge chairs) is located in a non-restricted hallway used by staff to access the dressing rooms.
b. The phase II area contains three lounge chairs. These chairs must be separated by curtains and there needs to be at least four feet between each chair and the seats should be placed to avoid visual contact from patient to patient.
4. The operating department does not have a designated preoperative patient holding area as described in "The Guidelines for Design and Construction of Health Care Facilities" 2010 edition chapter 2.1 sections 5.3.3.1.

Based on the observations tour with the infection control officer and interviews during the follow up survey , it was determined that the facility failed to promote a sanitary and safe care through its infection control program in the laundry department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include: Deficiency not corrected

1. Facility did not promote or operationalize procedures consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable diseases. The following was observed during follow-up survey procedures on 9/6/16 from 9:00 am till 3:00 pm related to infection control procedures:

a. In the facility laundry area there is no clear separation of soiled laundry space from clean laundry areas and soiled laundry who maintain negative pressure.

Facility engineer (employee # 4) stated on interview on 9/6/16 at 10:30 am that they plan to perform structural changes on this areas to comply with negative pressure requirements, he also show the blueprint. However quotation for this project were not provided or evidenced.


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c. On 09/06/2016 at 9:23 am during a tour with the DON (employee #1) it was identified on the third floor a room where the mechanicals ventilators were storage. The storage area was observed unorganized and the following was found:

In the same room that clean and disinfected mechanic ventilators were store it was found on the left side of the room multiples medical equipment and on the right side of the storage is a bed, a television, a red trash can (Biohazard), unsecure sharp container on the floor and another unsecure sharp container on top of a plastic drawers.

d. The facility fails to properly maintain the area to limit infection control risks and possible cross contamination.

Based on observations made of the surgical department on the Follow up Visit performed on 9/6/2016,it was determined that the facility failed to ensure that surgical services maintains a high standard of medical practice and patients' care.

Findings include: Deficiency not corrected

1. During the observation round to evaluated the Operating Room Department on in the main entrance of the operating room was observed a traditional living room recliner chair designated to seat the ambulatory patient's, this is and opening area used per the nurse to identified the patient and oriented related to the area designated to change the clothing and then the nurse accompanied the patient to the pre-anesthesia area. The area designated for this procedure receiving and oriented patients was located near the area designated and label read: " Area de Almacenamiento de desperdicios biomedicos personal autorizado solamente '' Area of storage of biomedical waste only authorize personnel, in this area was observed a small refrigerator and the nurse supervisor (employee #26) stated that the area was used also that the area was used also to place biomedical waste and the refrigerator for pathologies.